Smooth Transitions: Enhancing the Safety of Planned Out-of-Hospital - PowerPoint PPT Presentation

Smooth Transitions: Enhancing the Safety of Planned Out-of-Hospital Birth Transfers A Quality Improvement Initiative of the WA State Perinatal Collaborative

Midwives Association of Washington State http://washingtonmidwives.org/ • Approximately 120 Licensed Midwives in state • Attend >3% of all births or ~ 3000 births/year • 60% at home and 40% in licensed birth centers • MAWS has represented Licensed Midwives in state legislation and public policy since 1983 • After two decades of improving relations, home to hospital transfers suddenly became increasingly difficult in the early 2000’s

Washington State Department of Health Perinatal Advisory Committee • Representatives from the four regional perinatal networks, professional organizations (including MAWS), consumer groups, and state agencies • Purpose to review and assess perinatal health issues across the state • PAC adopted new Level of Care Guidelines for hospitals in 2005; MAWS brought the issue of problematic transfer to the committee at same time

MD/LM Workgroup Appointed in September 2005 as a subcommittee of the Department of Health’s Perinatal Advisory Committee  Charge: To study and improve the process of transferring women and their babies from a planned home or birth center location to an acute-care hospital when a higher level of care becomes necessary

MD/LM Workgroup

Smooth Transitions A Quality Improvement Initiative of the WA State Perinatal Collaborative www.waperinatal.org GOALS:  Build greater understanding between OOH birth midwives and hospital personnel  Improve interactions between providers when intrapartum transfers occur  Increase probability of safe and satisfying care for mothers and babies

Smooth Transitions • Activities • Smooth Transitions Project Manual • Outreach to local hospitals and midwives • Assess current situation • Presentations to hospital staff by midwife-physician team

Smooth Transitions • Activities • Encourage formation of a Planned OOH Birth Transfer Committee • Local Licensed Midwives • Obstetricians, Family Physicians, CNMs • Emergency Department Physician & Nursing Leadership • Obstetrics Nurse Manager • Obstetrics Charge Nurses • Hospital Administration Representatives (including risk management department) • EMS personnel • Follow-up assessment

ST Project Manual • Project Background • Licensed Midwives • Training • Licensure • Scope of practice • Data on outcomes transfer rates and reasons • Peer review and incident review program

ST Project Manual • Liability 
 Issues Hospitals and physicians will want to consult their legal counsel; however, it is our understanding that the professional liability insurance companies who provide obstetricians and gynecologists with professional liability insurance ask that their insureds not form formal, written consultation agreements with licensed midwives, which might be interpreted as the “loaning” of the physician’s liability policy limits to the licensed midwife. It is our further understanding that these companies do cover their insureds when their insureds are assigned to emergency obstetrical call as a condition of hospital privileges, and are then asked to care for any woman brought into the hospital for obstetrical care, including those women being transported who have been under the care of a licensed midwife.

ST Project Manual • MAWS Indications for Discussion, Consultation and Transfer of Care in a Home or Birth Center Midwifery Practice http://washingtonmidwives.org/for-midwives/indications- consultation.html

ST Presentation • Midwife-physician team meet with hospital staff • Powerpoint presentation addresses • Upward trends in OOH • Issues in transfer of care, lack of systemic support • National context, including AWHONN Position Statement on Midwifery, ACOG Statement on Home Birth, and Home Birth Consensus Summit

ST Presentation Home Birth Consensus Summit October 2011 Statement on Collaboration: We believe that collaboration within an integrated maternity care system is essential for optimal mother-baby outcomes. All women and families planning a home or birth center birth have a right to respectful, safe, and seamless consultation, referral, transport and transfer of care when necessary. When ongoing inter-professional dialogue and cooperation occur, everyone benefits .

ST Presentation HBCS Collaboration Workgroup May 2014 Best Practice Guidelines: Transfer from Planned Home Birth to Hospital

ST Presentation • Licensed Midwives • Training • Licensure • Scope of practice • Legend drugs and devices • Equipment and emergency skills • Health insurance contracts • Liability insurance • MAWS Quality Management Program • Data on intrapartum hospital transfers

ST Presentation  Intrapartum transfer obstacles reported by hospital-based providers:  Belief that home birth is unsafe  Burden of assuming care of unknown patient with elevated risk  Working with “difficult” patients or “difficult” midwives

ST Presentation  Intrapartum transfer obstacles reported by midwives:  Lack of awareness among hospital- based providers of OOH research supporting safety  Defense of co-negotiated assessment of risk  Feeling judged by the “exception rather than rule”

Model Practices for the Midwife In the prenatal period, the midwife provides information to the woman about hospital The midwife assesses the status of the care and procedures that may be necessary woman, fetus, and newborn throughout the and documents that a plan has been maternity care cycle to determine if a developed with the woman for hospital transfer will be necessary. transfer should the need arise. Model practices for the midwife The midwife notifies the receiving provider or The midwife continues to provide routine or hospital of the incoming transfer, reason for urgent care en route in coordination with any transfer, brief relevant clinical history, emergency services personnel and addresses planned mode of transport, and expected the psychosocial needs of the woman during time of arrival. the change of birth setting.

Model Practices for the Midwife Upon arrival at the hospital, the midwife The midwife may continue in a primary role provides a verbal report, including details on as appropriate to her scope of practice and current health status and need for urgent privileges at the hospital. Otherwise the care. The midwife also provides a legible midwife transfers clinical responsibility to the copy of relevant prenatal and labor medical hospital provider. records. Model practices for the midwife The midwife promotes good communication by ensuring that the woman understands the If the woman chooses, the midwife may hospital provider’s plan of care and the remain to provide continuity and support. hospital provider understands the woman’s need for information regarding care options.

Model practices for the hospital provider and staff Hospital providers and staff Hospital providers and staff are communicate directly with the sensitive to the psychosocial midwife to obtain clinical needs of the woman that result information in addition to the from the change of birth information provided by the setting. woman. Timely access to maternity and Whenever possible, the woman newborn care providers may be and her newborn are kept best accomplished by direct together during the transfer admission to the labor and and after admission to the delivery or pediatric unit. hospital.

Model practices for the hospital provider and staff Hospital providers and staff If the woman chooses, hospital participate in a shared decision- personnel will accommodate the making process with the woman presence of the midwife as well to create an ongoing plan of care as the woman’s primary support that incorporates the values, person during assessments and beliefs, and preferences of the procedures. woman. The hospital provider and the midwife coordinate follow up Relevant medical records, such care for the woman and as a discharge summary, are newborn, and care may revert sent to the referring midwife. to the midwife upon discharge.

Smooth Transitions Today 7 hospitals have had initial presentations: • University of WA Medical Center, Seattle • Evergreen Health, Kirkland • Providence Health and Services, Everett • PeaceHealth St. Joseph, Bellingham • Jefferson Healthcare, Port Townsend • Yakima Valley Memorial Hospital, Yakima • Kittitas Valley Healthcare, Ellensburg 3 other hospitals have expressed interest: • St. Joseph Medical Center, Tacoma • Providence St. Peter Hospital, Olympia • Valley Medical Center, Renton These 10 hospitals account for over 30% of state births

Smooth Transitions Lessons Learned • Home to hospital transfer is a systems problem – requires policy-level support • Cultivate respectful relationships built on sharing and listening • Identify local midwives and hospital staff who will “champion” the project • Engage all stakeholders • Maintain contact, follow-up • Paid project coordinator • Build on HBCS Collaboration, incorporate in pre- and post-assessment of project

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